Menopause Matters Forum
General Discussion => New Members => Topic started by: Mumto3 on August 23, 2024, 02:11:54 PM
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Hi Everyone
New to the forum. I'm perimenopausal, early 50's. Started HRT December 2023. I was still having regular natural bleeds pre HRT but had lots of debilitating symptoms, HRT allowed me to function again and it gave me my sanity back.
I use Oestrogel and Utrogestan. I soon discovered I couldn't tolerate Utrogestan orally. Vaginal was better (though not perfect).
I use: Oestrogel 2.5 pumps everyday & 1 x 100mg capsule vaginally days 15-26 (as a cyclical regime). This gives me regular bleeds, no spotting. Perfect cycle each time.
However, the BMS changed the schedule this year, to 2x 100mg Utrogestan capsules vaginally days 15-26. This is now in line with the oral doses, which doesn't make sense to me at all, as orally a lot of the Utrogestan is broken down in the liver and excreted before the body can use it. Vaginally it bypasses the liver and therefore there's a lot more absorbed.
I've been advised to up my dose to this new BMS dosing schedule.
I can't tolerate this 200mg dose vaginally. It gives me back the symptoms of the oral use (wired, anxious, panic attackey, thumpy heart, insomnia, foggy headed, low mood). So to me my body is simply telling me this dose is too high for me.
* Surely if my cycles are perfect with good full bleeds every cycle (by using Utrogestan 100mg vaginally days 15-26), the dose is adequate and doing its job?
* Another question: does anyone know Dr Louise Newson's latest dosing protocol for Utrogestan vaginally? It used to be half that of the oral dose? Has she kept it the same or changed it in line with the BMS?
PS my meno nurse suggested 100mg Utrogestan vaginally days 1-27 (as a continuous use instead), I'm not sure, because Utrogestan at the best of times makes my breasts full and tender and I can get snappy and impatient on it and my sleep isn't as good.
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You are correct in that the pharmacokinetics are vastly different with vaginal vs oral ingestion.
Your alternative is to continue with what works for you but get yourself a pelvic scan privately every year or so to monitor your endometrium.
Guidelines are based on the threshold that virtually guarantees endometrial protection in ALL women even those at high risk. This means others being overtreated but as the NHS hasn't the resources to scan everyone periodically, they have to err on the side of caution.
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Thank you for your reply and advice.
These new BMS guidelines do seem to be a one size fits all, regardless of the individual's biochemistry and hormonal levels. I asked a BMS nurse about these new dosing guidelines and how they didn't make sense to me. She just said that the BMS does a lot of research into this and we have to accept what they say. That's why I'm interested in what Dr Newson now says, as she doesn't seem afraid to prescribe with more flexibility.
We seem to be allowed to experiment with the oestrogen side of dosing by going on symptom response, whilst the progesterone side is fixed. It doesn't make sense to me. Our own body could still be making it's own progesterone as well as oestrogen in perimenopause (though at fluctuating levels I know). So there are some of us who feel over-medicated on Utrogestan at these fixed doses, as we would oestrogen, if those doses were fixed too.
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That's a good point - I think because the consequence of under treatment with progesterone over years, can lead to additional cases of endometrial cancer.
The harm associated with under treatment with estrogen such as women having a poor quality of life, osteoporosis and cardiovascular disease are perceived differently from a medicolegal standpoint.
Womens' quality of life is not considered a valuable outcome at all, and the latter are written off as diseases of aging or the patient blamed for their lifestyle.
Also given the difference timescales for these conditions to develop, the prescriber is likely to still be in practice when the endometrial cancer presents, but they will be long gone before the hip fracture or MI occurs.
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The NHS and the manufacturer have always thought you need 200mg x 12 days by either route, it was only Newson who said you could halve it for vaginal use. I believe she has stopped this advice. I don't think a decent bleed guarantees your lining is thin so if you can't tolerate any more utro imo your options are to try a different progestogen or to arrange your own periodic scans if you use less than the licensed dose of utro.
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OK, thank you Sheila99. I'm going to have a chat to my meno nurse.
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I took hrt including utrogestan vaginally from January 2023 until earlier this year. I was always told 2 x 100mg utrogestan even if used vaginally. I don't think the guidance is that new, and I believe Newson has bowed to pressure, as has Professor Studd's clinic. They also no longer support women doing utrogestan in lower doses or for less days.
I hated utrogestan with a vengeance for all the reasons you stated, and I'd often end up reducing to 100mg after about day 6 when the side effects became unbearable. If it were me and I wanted to continue with hrt, then I'd do the 100mg dose but get an annual scan privately to check lining isn't thickening too much. I'd not do it without supervision in the form of scans though.
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Hi Penguin
Thank you for your reply. Interesting you get similar side effects. I presume from what you say, you're not taking HRT anymore? If you are, do you mind me asking if you still take Utrogestan? If so, how and what dose? Can you get a private scan without a Dr's referral i.e. can you self refer?
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No, I ended up stopping hrt in April this year because I couldn't handle utrogestan and feeling like that every month and didn't want to take a synthetic progestin instead. Plus I am still in peri and was getting estrogen surges that meant I struggled getting the estrogel dose right.
Yes you can get a private scan without referral. Some women on here use ultrasound direct, which is where I think you get pregnancy scans. They are all over the UK, bit I'm sure there are other places.
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Hello Mumto3 and welcome to the forum.
I spoke with an NHS consultant about eighteen months ago and he was worried about the lower dose Utrogestan that many women were using. He knew of other senior medics who were talking to the BMS about their concerns.
Earlier in the year I used Ultrasound Direct and found their service to be very good. I emailed all my results to my GP and they agreed that as a consequence I didn't need an NHS referral.
Wishing you well and take care.
K.
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Hi Penguin
I can understand your reasons there. I simply couldn't cope/function without the oestrogen part of the HRT. So I've felt a bit stuck with this, as I too don't want to use the synthetic progestogens. So I'm trying to find a way to make the Utrogestan work at a level that's also protecting my endometrium. I hope you're managing ok, now you're off the HRT. It's a bumpy old journey isn't it.
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Hi Kathleen
Thank you for your reply and the information you've given. :-)
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Hi Penguin
I can understand your reasons there. I simply couldn't cope/function without the oestrogen part of the HRT. So I've felt a bit stuck with this, as I too don't want to use the synthetic progestogens. So I'm trying to find a way to make the Utrogestan work at a level that's also protecting my endometrium. I hope you're managing ok, now you're off the HRT. It's a bumpy old journey isn't it.
Hi I have sent you a private message x
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Hi Penguin
Thank you for your PM. I don't seem to be able to reply to it. Tbh, as a newbie I'm finding this forum hard to navigate. I used to use Healthunlocked for thyroid advice and found the format for that a lot easier. Anyway, thank you for the time you've spent offering advice :-)
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Ah I think you may have had to comment on a post 10 times before you can pm or something like that
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Thank you for your reply and advice.
These new BMS guidelines do seem to be a one size fits all, regardless of the individual's biochemistry and hormonal levels. I asked a BMS nurse about these new dosing guidelines and how they didn't make sense to me. She just said that the BMS does a lot of research into this and we have to accept what they say. That's why I'm interested in what Dr Newson now says, as she doesn't seem afraid to prescribe with more flexibility.
We seem to be allowed to experiment with the oestrogen side of dosing by going on symptom response, whilst the progesterone side is fixed. It doesn't make sense to me. Our own body could still be making it's own progesterone as well as oestrogen in perimenopause (though at fluctuating levels I know). So there are some of us who feel over-medicated on Utrogestan at these fixed doses, as we would oestrogen, if those doses were fixed too.
Hi mumto3
Have had a quick read of ths thread.
As per sheila99 - the guidelines have not changed at all. Vaginal use of Utrogestan for HRT is unlicensed in UK though off license (label?) women have been prescribed and have used it in this way ever since it was first licesned for HRT. And as per sheila, the manufacturers, Besins, in their product guidelines for its use in France, give vaginal use as an alternative to oral intake for those who do not tolerate oral dosing, and give the same dose for each.
The Newson approach - to halve the amount when taken vaginally to give the same effect, was based on limited trials which showed that for low to medium dose oestrogen ( 25 mcg -50 mcg patches if I recall correctly), alternate day dosage did not lead to thickening of the endometrium under the conditions of the trial.
I can find you the thread where I posted the abstracts of the papers if you like?
As a result of these trials some private clinics, notably Newson Clinic, generalised this to be a universal recommendation. In fact the research simply has not been done for higher doses of progesterone as far as I know and this was being taken as proper guidelines - whereas it was just the recommendations of one private clinic, in the same way that Studd used to recommend 7 days per 28 progesterone for prog intolerant women.
It;s a good thing BMS came up with the guidelines, due to the widespread use of HRT and esepcially vaginal use of progesterone. It's great if it can be personalised but the NHS just can't afford to scan everyone - who take less than licensed doses, hence these recommendations.
It does make sense to require a higher dose of prog for a higher dose of oestrogen because it has always been known that the protective effect of prog on the endometrium is duration and dose dependent, and dependent on the dose of oestrogen.
Hope this is helpful
Hurdity x
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I completely get where you are coming come.
I couldn't tolerate Utrogestan at all. I had horrific side effects. I cannot seem to tolerate progesterone very well.
In the end I had to go private and I am now on 100mg cyclogest every other day along with 3 pumps of lenzetto and have a scan every year to check the thickness of the lining of the womb.
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It's such a shame women are having to pay privately for a more tailored approach to their HRT regime.
Trying to persuade us one size fits all is a bit like kidding a size 10 and a size 20 that we'll both feel comfortable in the same pair of tights!